In the world of procedures, all procedures are not created equal. And when that happens, the turf wars begin. I can assure you, in just about every hospital in this country, behind the scenes politics go hand in hand about who has the right the perform what. The battles usually ensue, in those procedures that are economically worth while to the doctor or group of doctors
There are some procedures that are not "owned" by specialties. Physicians get credentialed to perform a whole host of procedures.
When I was in residency, I had to keep track of all my procedures.
Central lines
Lumbar Punctures
Thoracentesis
Intubation
Paracentesis
Arterial Blood Gas
This was part of my training as a resident, to become proficient in these types of procedures. For other residencies, the expectation of proficiency was determined by the specialty and the program.
Number of EGD's, Number of colonoscopies. Number of heart caths. Number of explorations. Number of total knees.
What ever. You keep track.
When you go out into practice, your record of experience may be called up for "proof" by your new hospitals that you know what you are doing when you do any type of procedure. Placing a needle in hollow spaces. Sticking a scope in hollow spaces. Putting a catheter in a blood vessel. I can't really speak for surgeons, but I would think their credentialing requires proof of numbers of surgeries as well.
But as you know, not all procedures are owned by one specialty.
I do central lines. Surgeons do them. Anesthesia does them. FP's do them. I'm sure pediatricians can do them as well. Nephrologists do them.
EGD and colonoscopy, training in this procedure can be procured by FP's, surgeons, internists, gastroenterologists.
Vascular diseases/stents/angiograms. Surgeons, cardiologists, interventional radiologists, others.
These are just some examples of procedures which are credentialed by different specialties.
The problems occur when battle of the "turf wars" begin.
In my 5 years as a hospitalist, I have seen turf wars develop for different procedures.
PICC lines
Vascular intervention
Colonoscopies
Vascular study evaluation
I'm sure there are others. And I'm sure there are turf wars at hospitals all over this country.
Ours is no exception.
Why?
Why are there turf wars?
My assumption is its about money. The battle for that Medicare Dollar from the Medicare National Bank. These types of procedures pay well, relative to the risk involved, volume generated, time spent and payment for alternative encounters of care (ie cognitive).
Now granted, extra training is required in specialty training and with that extra training comes the benefit of higher income. Of course that is accepted.
What I find highly interesting is that not once have I ever heard of a turf war developing in the following procedures which, like angiograms, colonscopies, heart caths, etc require a level of repetition and expertise to limit complications:
Thoracentesis
Paracentesis
Lumbar Puncture.
Bone marrow Biopsy
In fact, Often times I find it very difficult to find any specialist in their field of expertise who will perform these procedures for my patients.
To me, the reason is obvious. Money.
The Medicare National Bank, pays these procedures at an approximate rate of a level 2 hospital follow up visit. In other words
It aint worth the time for most specialists.
A level two follow up visit can be documented on paper in about a 10 minute visit. Tops.
These are procedure that have been banned to the interventional radiologists or me (if I'm comfortable) or my partners (that are comfortable) because it is not worth the opportunity cost of that time for my specialists to do it. I will occasionally get lucky and find docs to do it. The pulmonologists are especially good about doing their own throacentesis. But in general, the opportunity cost of doing a paracentesis, is a colonoscopy that pays 3 times more in about the same period of time.
Why should I have to send a patient of mine to get a lumbar puncture by an interventional radiologist who may use fluroscopy, has a whole team of nurses and will likely bill out an extra ordinary facility fee for the use of all that great technology when the specialist, who learned that skill in their training can do it quite quickly and comfortably at the bed side.
It's because these procedures have been labeled the Red Headed Step Children of the Procedure World.
They are the primary care of the procedure world.
I would also like to know why I can't find a single gastroenterologist in 5 years in my town that will take the time out of their busy day to do a paracentesis on a patient of mine, a procedure they trained for in their 3 extra years of specialty work, but will kindly spend all day in the endoscopy lab with their extenders rounding all day.
I think you all already know the answer why.
At least at my institution, this is my experience.
No offense to red headed step children. Please don't flame me for that. It was a figure of speech.
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Tuesday, January 8, 2008
Red Headed Step Children
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24 Outbursts:
In my IM residency, paracentesis, thoracentesis, LP were all part of the required procedures. I wonder why the hospitalists have to call for people to do those simple procedures, especially if they are worried about the costs?
anon. I HAVE done all three of these. But not in numbers to make me feel comfortable about doing it right every time. I suppose if you were on the other end of my needle as I enter your spinal canal, you wouldn't want to hear me say this is my 3rd LP in 5 years. Would you?
I will chose patient safety over cost every time.
And if they are so simple, I don't understand why my specialists don't feel the desire to do them. They're quick and easy, right?
You are the one stating that it was wasteful to use flouroscopy when doing their procedures. How would you know how comfortable they are without flouro? How many do you think each radiologist does? Would you want your doctor saying I can't do it the way I am used to doing it because of the cost?
You want to choose patient safety, and who doesn't? but you won't re-learn simple procedures that would provide better care for your patients, in the setting you describe. Everyone has to do a procedure for the first and second time. I think longterm if you offered them, you would acquire the skills that would benefit many patients, and that would offset the risks to the specific patients while you relearned them. Especially if you relearned them under careful observation. There are classes you can take. I would argue everyone has abandoned these procedures, including primary care.
anon. I don't have a problem using fluroscopy. The comfort level of the doc determines how the procedure is done.
I could certainly relearn these procedures. You are correct. And maybe I should. But the point was not whether I as a hospitalist should learn to do a procedure that specialist trained for 3 years doing 100's of them.
My point was that nobody wants to do them because for the time it takes from start to finish, it aint worth the money it pays.
Pass the buck to someone else, such as a hospitalist, or how about interventional radiology. They do pretty much everything.
You are correct specialist and primary care, everyone has abandoned these procedures. But I didn't three extra years of training to learn how to do them well either. I did only a handful in training.
When a gastroenterologist says that primary care shouldn't do colonoscopies because they don't do enough and risk harming the patient, I have never heard this argument about paracentesis. There will never be a turf battle for paracentesis, until the money makes it so.
If you have a business to run, of course you are going to choose activities that are the most profitable.
No matter what you want to think, medicine is a business.
I don't blame doctors for wanting to make the most of their time.
Happy,
Could not agree more, as usual spoken from someone in the trenches. I am a salaried Hospitalist. My days are busy enough trying to diagnose/manage many patients and if you add on a few procedures makes my day even longer without any increase in compensation. I did enough of these procedures in residency to feel comfortable doing them 90% of the time. BUT, if I do them now I am not compensated for them and I have increased my liability if something " bad" happens. All the risk without any of the benefit.... sounds good to me... sign me up for that one skippy... NOT.
Why would you ever sign a contract that didn't reward you in some way for doing more?
Anon 5:34,
Good point. This was my first contract, the " standard " one used by the Hospital. I did have it reviewed by an attorney ( eg no non-compete clauses, good tail coverage provided by the Hospital)but that piece " slipped through the cracks". It will not in the next contract ( currently negotiating). Damn, I just wish somebody during residency would have taken a bit more time to go over these things. Oh yeah, I forgot I was spending my time and energy learning how to practice MEDICINE. I will have a different attorney review the next contract ( my pockets are a bit deeper now than when I left residency). A day older, a bit wiser, I hope.
so since you feel comfortable with these procedures 90% of the time, if you were reimbursed adequately for them, would you perform them?
i have no idea what adequately means to you, butlet's say the same as a level 4 consult initial encounter. would that make it worth it to you?
ps-don't feel bad about not negotiating the first contract. we all have to learn. most housestaff, even if they are educated on the basics of the matter, lack the experience to effectively negotiate anyways. still job selection and contract negotiation may be the biggest thing you do during residency, yet the program directors are trypically scrooges about letting you have enough time to make a good decision (understandable in some ways, since i am sure there would be widespread abuse without). still i am hard pressed to believe there couldn't be a better balance.
the thing is-if they won't offer you a decent first contract, i'm not sure they have your best interests in mind. i've never not offered anyone incentives for production in any contract i've ever offered to physicians. as much as the administrators and business people argue that we are simple service providers, don't let them sway you from knowing you are truly valuable and won't be commoditized. i friggin hate when a nurse or tech by training/experience come coo tells me something stupid like that. they love to say they put their time in, so they can say it. yeah right.
well good luck with everything.
Anon 6:55/7:05
I would certainly do more of these procedures if I was adequately reimbursed. I think a level 4 consult charge would be an adequate reimbursement for these procedures. Of course that is before the "contractual discount" is applied. By my understanding the Hospital collects about 40% of what I bill out, and most of this discrepancy is not due to uninsured/indigent care but rather contractual discounting. I agree with Happy, when you see the subspecialists become interested in these procedures again, or asking for privileges for their extenders to do these procedures " under their supervision", that is the level when it becomes cost effective to do them. I am not in private practice and do not deal directly with the financial aspects as much as private MD's do, so watching their behavior is a reasonable gauge of what incentives are currently present in reimbursement. Thanks for your encouragement and advice concerning the next contract. I enjoy my colleagues/work environment and I am hoping a mutually beneficial outcome can occur.
thanks for answering, i definitely don't disagree that the procedures that are less cost effective are not done as much, but i would hope that when they are needed they get done. i also suspect that in academic medicine, the specialists have different incentives as well-i'm not sure it is as purely cost based as happy asserts private practice is?
in our multispecialty group of well over 100 physicians, we do not allow consults to be performed by physician extenders. it would be much more time effective to allow it, but we don't believe the requesting physicians get the same level of service consistently. a lot of the physicians complain bitterly about it, but in the end, they abide by our final group decision. it also makes it difficult to pay physician extenders since they no longer really directly bill that much, so they are not revenue centers, as in other practices.
is it so hard to believe the specialists are busier with other things that only they can do rather than basic procedures that technically can be performed by other services?
Anon 9:09 says: is it so hard to believe the specialists are busier with other things that only they can do rather than basic procedures that technically can be performed by other services?
I think that is one of the problems. Almost every physician I know is as busy as they want or care to be. So, in that environment, everyone is trying to " optimize" their time. I tend to turf these basic procedures to the interventional radiologist because I am usually busy enough caring for the patient and I don't get reimbursed for the procedure like the radiologist does. The most important " procedure" I bring to the table is thinking!! For the patient's sake my time is best spent making or helping to clarify a diagnosis and formulating a treatment plan with the least number of invasive procedures possible. If I was a nonthinking Hospitalist/internist I would just " machine gun" consult like the Neurosurgeons do ( abd pain: GI or Gen Sx, cough: Pulm or ID, chest pain: cardiology, diabetes: endocrine). This is not to " bash " Neurosurgeons, they are not dumb!! They don't get paid to manage that stuff either. Now with hospitalists around they consult us and we manage all of that and we will get the appropriate subspeciality involved if we need their help. I digress, it appears to me that everyone has enough work to do, the least attractive work gets pushed to whoever will do it. My patients get the procedures that they need done. If I don't perform my job well, they may get procedures that they don't need done.
Wow, I'm kind of amazed. I trained in the 70's so maybe I'm too old to comment, but in "my day" the procedures you listed were part and parcel of inpatient acute care and I would expect a hospitalist (which didn't exist when i trained of course) to do them as a matter of course. Perhaps, then, this should be part of your contract as a matter of course. Frankly I can't see calling a specialist who may not be in the hospital to do these things, which may need to be done fairly emergently for diagnostic or therapeutic purposes.
Perhaps this is why i am reading about yet a new specialty called the "proceduralist"?
i don't know where to put this comment but what did you do to that poor dog? red santa jacket?
anon453.
I understand that primary care, hospitalists should be able to do these procedures. And I should be able to do them my self. I do quite a few paracentesis and central lines. The others I am much less comfortable. There are people in my group who do all of them.
But you have missed the point entirely. The issue isn't why I'm not doing them, it's why the specialists, who trained for 3 years, doing 100's of them (I'm sure) aren't doing them.
They are too busy? Doing what? Better paying procedures?
Let me put it in perspective. The blog entry was meant to show that these specific procedures are not part of the turf war battles fought between different specialities to get hospital privileges because they don't pay squat.
Let's imagine if I decided to go take a course on colonscopy and got certified with experience, say, at a small town hospital where primary care does there own endoscopy. I'll tell you exactly what would happen if I tried to get privileges at the hospital. There would be a giant uproar by GI that I was treading on their territory.
My point isn't that I don't do them, which I should. The point is that the specialists don't because other encounters/procedures are much more worth their time. And if others try and get credentialed for the lucrative procedures, a turf war would ensue.
So these poor low paying procedures get banned to the interventional radiologists or hospitalists.
If there are any GI docs out there I would love to here a counter opinion.
That's my anon post, I'm not sure what happened
Anon736, That's Cooper. He's our little Santa trooper. Full of love.
No, I didn't miss your point; and turf wars are certainly not a new issue; I saw them way back in "my day" also. And yes, they will always be over money, no matter what other excuse the combatants make.
The point I was trying to make was that the specialists are not doing the things you listed because they don't belong in the specialists' arena, not because they don't pay well. I am just respectfully disagreeing with your conclusion. Perhaps the advent of surgical hospitalists will take care of this problem; they can do them. As my surgeon husband points out, they can also put in the chest tube if they drop a lung doing a thoracentesis.
I would venture to guess that if a paracentesis was worth $200 a pop that I would have GI docs jumping over my toes at the credentialing committee to prevent me from doing them.
If I can train for both a paracentesis and a colonoscopy, why is it that only the colonoscopy is sacred ground for the GI docs and they will battle till death their right to be exclusive providers.
It most certainly has everything to do with money. The only reason paraacentesis is not in the "specialist arena" is because they chose not to make it so, based on reimbursement.
OK, let's extend this discussion, since I am a regular (though reluctant) colonoscopy patient, the first one in 2004 after an episode of BRB per rectum. I had a 3 mm adenomatous polyp, which as a pathologist I can tell you is pretty unusual (most polyps that small are hyperplastic). It was read as containing "moderate dysplasia". Then 18 mos later there was another one, same size, same area, but not sure if it was a recurrence of the original one since the colonoscopist failed to tattoo the original one. Again, some dysplasia found. This worried the GI person who said if she found a 3rd one next time she'd recommend a resection (which I thought was extreme.) So on to a 3rd procedure two months ago, which fortunately was clean.
Sure, you can train to do the procedure, but are you prepared to keep up with the GI literature and knowledgeably discuss with the patient (particularly a picky M.D. patient like me) what the risks, benefits, prognosis, future recommendations, etc. should be?
And then if you want to train to do liver biopsies, or whatever else pays well, are you going to study up on hepatomas, all the various forms of hepatitis, etc., etc.?
As well as take good care of all your inpatients as a hospitalist?
I can see turf wars over money between specialists who are trained to do the same things, like orthopods and neurosurgeons. But as for those who just want to be technically trained and paid for the procedure, that ain't enough to be able to take care of the patient.
according to your cms calculator, the paracentesis pays $175 in my area.
anon 453
welcome to happy's world.
he actually doesn't need specialists except for procedures and cancer. :)
anon833, I suspect what you are reading is $175 if it's done in the office.
If it's done in the hospital (Facility) it pays about $60.
anon453, I wouldn't take on any type of medical intervention or care that I wasn't comfortable managing correctly.
As far as biopsies, such as lung, liver, kidney, the interventional radiologists are well trained to do the procedure, and I can assure you they are no experts in the management of the result of the biopsy.
it's 175 for the nonfacility fee, correct.
Facility: Includes hospitals (inpatient, outpatient, and emergency department), ambulatory surgical centers (ASCs), and skilled nursing facilities (SNFs).
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